Running head: KANGAROO CARE 1

Kangaroo Care and Low Birth Weight Infants

Megan Lammers
Ferris State University















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Abstract
In this paper a clinical question based on a nursing problem of Kangaroo Care and low birth
weight infants was developed and discussed. Described are the methods used to search the
evidence available, including definitions of the levels of evidence, and nursing research
available. Also explained are the inclusion and exclusion criteria. Next, three articles that were
found showing evidence of Kangaroo Care with relation to low birth weight infants were
critiqued including an overview of the article results. Results showed that kangaroo care is
associated with an increase in weight gain compared to control groups. Finally discussed is the
significance of the evidence findings to the nursing problems and a response to answer the
clinical question.










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Kangaroo Care and Low Birth Weight Infants
Introduction
The purpose of this paper was to develop a clinical question based on a nursing problem.
The method to search for the evidence available is described, including a definition of the levels
of evidence and the nursing research available. Using the evidence available, a response was
formulated to answer the nursing problem. The clinical question is in low birth weight infants
how does the use of Kangaroo Care compared with no Kangaroo Care affect weight gain?
Clinical Question
The World Health Organization estimates that more than 20 million infants worldwide
are born with low birth weight, and this constitutes for 15.5 per cent of all births (Wardlaw,
Blanc, Zupan, & hman, 2004). For clarity, low birth weight is defined as the weight of the
fetus obtained after birth of less than 2,500 grams or 5.5 pounds ( Failure to Thrive, 2013, pg.
1). With this nursing problem a clinical question was formulated. The clinical question is in low
birth weight infants how does the use of Kangaroo Care compared with no Kangaroo Care affect
weight gain? The paper researched the effect of Kangaroo Care in low birth rate infants. With the
number of infants born in the world with low birth weight, future nurses need to be aware of this
problem and know ways to help those infants gain weight. Infants born with a low birth rate are a
nursing problem because this population is at risk for failure to thrive. Failure to thrive is
defined as children who do not grow and develop normally as compared to children of the same
age (Failure to Thrive, 2013, pg.1). They may suffer from symptoms such as height and weight
that do not match standard growth rates. Development and growth may be affected if a child fails
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to thrive for a long time. Potential complications such as permanent mental, emotional, or
physical delays can occur.
Methodology
The methodology behind formulating a PICO question begins with finding a topic of
interest and beginning to formulate ideas of a nursing problem dealing with that topic. PICO
questions are composed of four parts. They include a population (P), intervention (I), comparison
(C), and an outcome (O). Formulating a PICO question begins with a patient population of
interest. In this paper the population of interest is low birth weight infants. In this case the
intervention or area of interest is Kangaroo Care. Next comes, a comparison intervention of the
group, and finally an outcome is achieved. With the PICO question formulated then the research
can begin.
After going into Cinahl, which is a research data base, researchers pulled apart the
question to research using key words like Kangaroo Care, low birth weight, or weight
gain. Next under an advanced search, items such as research articles, peer reviewed, and
publication dates were chosen. Using these search criteria, it narrowed down the results to get
only research articles that were under the advanced search items selected. After those results
were reviewed, the researcher then went back and did another search with synonyms as the
search topics such as skin to skin contact and underweight. Using these search topics yielded
different results. Next the researcher needed to review the research articles and choose what to
use in the paper. The researcher looked at articles from other multidisciplinary areas since as
defined by Rose Marie Nieswiadomy (2012), nursing research is a systematic, objective process
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of analyzing phenomena of importance to nursing (pg. 3). Finding medical articles from other
disciplines opens the doors for multidisciplinary research.
While reviewing the articles found during the searches, the researcher needs to be aware
of the exclusion/inclusion criteria. The inclusion criteria includes high levels of evidence.
Researchers want to find the highest level of evidence to present to the audience. They want to
look for systematic reviews which are the highest level of evidence. With research most often
they see low levels of evidence such as case control studies or expert opinions. Level of evidence
according to QSEN begins with the lowest level as expert opinion, going up to case reports, and
case control studies, as low levels. Next to come are cohort studies, randomized control trials and
lastly, systematic reviews as the highest level of evidence. The exclusion criteria includes
research articles that are older than five years. The researchers want to provide the most up-to-
date information, so looking for the most up-to-date research articles is important. Another part
of the exclusion criteria would be articles that involve advanced practice nursing. Researchers
need to use articles that are nursing research rather than advance practice nursing because as
nurses they need to learn and be aware of the research results specific to their degree so they can
apply it to their practice. With the research done through Cinahl, three articles were found and
reviewed.
Discussion of Literature
Article 1
The first peer reviewed article by Drs. Samra, Taweel, and Cadwell focused on the effect
of Kangaroo Mother Care (KMC) on weight gain of low birth weight (LBW) neonates. The
article came from The Journal of Perinatal Education and focused on low birth weight infants.
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The literature did support the need for this study because some of the references are out of date,
and there are many debates on the benefits of KMC. The purpose was to study the advantages of
KMC with increased opportunities to breast feed in LBW neonates who did not start to gain
weight after day seven. The study consisted of 40 LBW neonates who met the inclusion criteria,
whose parents were informed about the study and were asked if they would like to participate.
All participants signed consent and were randomly assigned to two groups. Twenty-two neonates
were placed in the KMC group, which was mothers doing skin to skin twice daily for an hour.
The remaining 18 neonates received routine care. According to QSEN levels of evidence this
article fell in a higher level of evidence because this was a random control trial. The statistical
analysis used in this study was the Chi-square test. For this study the level of measure and the
statistical analysis do match the nominal measure of data presented in the figures, showing there
was significance with weight gain with Kangaroo Care, the same that was presented in the
statistical analysis.
The results of the first article showed that in the KMC group, the average daily weight
gain was significantly higher (Samra, Taweel, & Cadwell, 2013, pg 5). The mean daily weight
gain was significantly higher in the KMC group compared to the control group. The results
were clear in describing that the Intermittent KMC was found to be a safe, effective, and feasible
method of care of LBW infants admitted to the NICU( Samra, Taweel, & Cadwell, 2013, pg 7).
While the results were clear, there was a threat to the internal validity. One threat to validity
would include selection bias. While parents were asked to participate and did sign a consent,
many of the parents that participated might have been more passionate about Kangaroo Care and
done more skin to skin contact daily. Besides that one threat to validity the researchers took close
care of baseline values and physical and environmental factors keeping both groups matching.
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The conclusion of the results from this study are similar to the other studies described later in
this paper, that the weight gain in the infants was significantly higher in the KMC group
compared to the control group. With these results, future nurses can teach their patients and
apply these findings to their patients about the importance of skin to skin contact. It helps the
infants gain weight so they do not suffer with failure to thrive. Nurses can tell their patients that
intermittent KMC was found to be effective in improving weight gain in neonates who have low
birth weight.
Article 2
The second peer review article was written by Agustin Conde-Agudelo

and Jos L Daz-
Rossello, both of who are a part of the National Institute of Child Health and Human
Development. The Cochrane Neonatal Group was the source of this article that focused again on
the problem of low birth weight infants and the effects of Kangaroo Care. The background
literature did support the need for this study for two reasons, one because there is still debate on
what the benefits of Kangaroo Care are and two because there was not any updated systematic
review available for researchers. The purpose of this study was to determine whether there is
evidence to support the use of KMC in low birth weight infants as an alternative to conventional
neonatal care (Conde-Agudelo, & Daz-Rossello, 2013, pg. 4). Also this study looked at the
effects of KMC and mortality and morbidity. This population consisted of 2,751 low birth weight
infants again defined as an infant less than 5.5 lbs. This study was composed of 17 randomized
control trials in which KMC was compared with conventional neonatal care. This article was a
systematic review, which is the highest level of evidence. The statistical analyses used in this
article were risk ratio and mean difference. For this study the level of measure and the statistical
analysis do match the nominal measure of data presented in the figures, showing there was
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significance with weight gain with Kangaroo Care, the same that was presented in the statistical
analysis.
The results of the second article did answer the question of if low birth weight infants
who had Kangaroo Care had more weight gain then those infants with no Kangaroo Care. The
results showed a significant increase in infants weight gain with Kangaroo Care. The results of
the study also showed compelling evidence that KMC is associated with a reduction in
mortality at discharge, severe infection, hypothermia, and length of hospital stay (Conde-
Agudelo, & Daz-Rossello, 2013, pg. 5). Lastly, this study showed that KMC is associated with
breastfeeding duration which benefits both the mother and baby. The results are clearly stated,
however there were a few threats to validity that could have off set the results in that 10 studies
were performed in neonatal intensive care units of tertiary care, public, maternity, or university
hospitals( Conde-Agudelo, & Daz-Rossello, 2013, pg. 8). With results coming from many
different places, some facilities for example a Kangaroo unit at a Neonatal intensive care facility
may have different feelings about Kangaroo Care then a university hospital. Also with this
different techniques could have been used while weighting the babies in all the different
facilities. For example some may weigh the infant with a diaper and cap while others may weigh
the baby completely naked. Using these different techniques may have affected the results. The
conclusions are similar to the results of other studies providing strong evidence on the
importance and benefits of Kangaroo Care. The results of this study can be applied to future
patients in a clinical setting because nurses can inform them of the benefits of KMC, not only for
weight gain, but also as shown in the results of this study a reduction in hospital stay and severe
infection. Also nurses will be able to inform their patients that KMC is associated with a longer
breastfeeding duration with the infant.
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Article 3
The last peer reviewed article from the Journal of Neonatal Nursing was written
by Nirmala, a nursing professor, Rekha a pediatric nurse, and Washington, a consultant for
health personnel. The authors focused on KMC and the effect and perception of mothers and
health personnel. The background review did support the need for this study, due to the low
levels of evidence. The problem investigated in this study was the perception of mothers and
health personnel towards Kangaroo Care. The purpose of the study was to see how mothers felt
about kangaroo care with things such as sleep hours, weight gain, and security for the infants.
The sample consisted of 50 neonates and their mothers. Thirty one infants were from the NICU
and nineteen from the obstetric unit. This article fell in the lower levels of evidence. The design
of the study consisted of repeated measures multivariate analysis of variance (RMANOVA).
The statistical analysis used consisted of two repeated measures. For this study the level of
measure and the statistical analysis do match the nominal measure of data presented in the tables
and graphs, showing there was significant evidence that Kangaroo Care does effect hours of
sleep, aid in weight gain and stimulation, and the same that was presented in the statistical
analysis.
The results from the last article critique first the need to be noted as outside the inclusion
criteria due to the date of publication. This was included because it focused on what the mothers
felt about Kangaroo Care. Mothers explained that they felt KMC provided warmth for the baby
(44.4%); facilitated in longer sleep hours (51.1%); made the baby secure (37.5%); provided
stimulation for the baby (33.3%); and aided in weight gain (55.6%) (Nirmala, Rekha, &
Washington, 2006, pg. 5). The results were clearly stated, however a threat to validity that may
affect the results would be selection bias. Mothers were selected to participate in the study and a
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consent was signed. Also a possible threat to external validity in this study would be Hawthorne
effect described by Nieswiadomy as occurring when study participants respond in a certain
manner because they are aware that they are being observed (Nieswiadomy, 2012, pg. 117).
Mothers may have done more skin to skin contact due to the fact they knew they were
participating in this study. The results are consistent with similar studies out there again showing
only benefits to KMC. These study results mean education is needed for nurses on behalf of the
patients. Nurses need to take on the responsibility and promote the concept of KMC for the long
term home setting. These results should be applied to clinical practice in that nurses should
educate their patients that long term Kangaroo Care has benefits such as weight gain, stimulation
and warmth of the baby. KMC in the home setting can have long-lasting effects and mothers
should not only be motivated to do KMC while in the hospital, but also carry it into the home
setting.
Significance to Nursing
The evidence found in the three articles that were reviewed all had significant findings
that showed positive effects on low birth weight infants. Low birth weight infants are at risk for
failure to thrive when born under 5.5 pounds. With mothers doing intermittent or continuous
Kangaroo Care, the results of these articles showed there was a significant weight gain with
infants who received the KMC. The findings can be integrated into practice to sustain quality and
safety of low birth weight infants in that nurses can educate their patients on the benefits of
KMC. The evidence supported the benefits of breast feeding duration, weight gain, and reduced
hospital stays.
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According to QSEN quality improvement is defined as the use of data to monitor the
outcomes of care processes and use improvement methods to design and test changes to
continuously improve the quality and safety of health care systems (Drenkard, 2013, pg. 6).
With the evidence found in the article critiques researchers can use the methods of caring for low
birth weight infants by involving kangaroo care to improve the quality of the health care systems.
Using the Knowledge, Skills, and Attitudes (KSA) according to QSEN, with this paper the
researcher searched for information about outcomes of care for a population that is served in a
care setting. With the information found about the benefits of Kangaroo Care future nurses will
be able to inform their patients about the outcomes of care in the setting in which they are in
clinical practice. Lastly nurses need to appreciate that quality improvement continues as an
essential part of the daily work of all health professionals.
Lastly according to the American Nurse Association, Scope and Standards of practice
under the health teaching and health promotion, nurses need to employ strategies to promote
health and a safe environment. Nurses need to provide health teachings that address topics such
as developmental needs (Nursing Scope and Standards of Practice, 2010, pg. 41). As discussed
previously, low birth weight infants are at risk for failure to thrive and developmental needs.
Educating mothering patients about the benefits of Kangaroo Care with weight gain,
breastfeeding duration, stimulation, and infant security is very important and a responsibility. So
as nurses need to help the more than 20 million low birth weight infants born to the world each
year by promoting Kangaroo Mother Care.



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References
Conde-Agudelo A, Daz-Rossello JL.(2014). Kangaroo mother care to reduce morbidity and
mortality in low birth weight infants. Cochrane Database of Systematic Reviews, Issue 4.
doi: 10.1002/14651858.CD002771.pub3.
Drenkard, K. (2013). Level of evidence review. In American Association of Colleges for
Nursing QSEN . Retrieved July 13, 2014, from
http://www.aacn.nche.edu/qsen/workshop-details/new-orleans/KD-EBP.pdf
Failure to Thrive (2013, August 22). In Medline Plus. Retrieved August 1, 2014, from
http://www.nlm.nih.gov/medlineplus/ency/article/000991.htm
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Saddle River, NJ: Pearson Education.
Nirmala, P., Rekha, S., & Washington, M. (2006, September 7). Kangaroo Mother Care: Effect
and perception of mothers and health personnel. Journal of Neonatal Nursing, 12(5),
177-184. doi:10.1016/j.jnn.2006.07.008
Samra, N. M., El Taweel, A., & Cadwell, K. (2013). Effect of intermittent Kangaroo Mother
Care on weight gain of low birth weight neonates with delayed weight gain. Journal
of Perinatal Education, 22(4), 194-200. doi:10.1891/1058-1243.22.4.194
Nursing Scope and Standards of Practice (2nd ed., p. 41). (2010). Silver Spring, MD: American
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Wardlaw, T., Blanc, A., Zupan, J., & hman, E. (2004). Low birth weight. In World Health
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